Provider Demographics
NPI:1508336504
Name:TIERCE, LAWRENCE MARVIN (PT)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:MARVIN
Last Name:TIERCE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 AVIGNON DR
Mailing Address - Street 2:
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-5120
Mailing Address - Country:US
Mailing Address - Phone:601-605-6777
Mailing Address - Fax:
Practice Address - Street 1:512 ROCKWELL DR
Practice Address - Street 2:
Practice Address - City:OKOLONA
Practice Address - State:MS
Practice Address - Zip Code:38860-1622
Practice Address - Country:US
Practice Address - Phone:662-447-5777
Practice Address - Fax:601-607-1381
Is Sole Proprietor?:No
Enumeration Date:2018-12-03
Last Update Date:2018-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT239225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist